Healthcare Provider Details

I. General information

NPI: 1548799141
Provider Name (Legal Business Name): SAMUEL OLAOLUWA OMOLADE APRN PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 07/15/2023
Certification Date: 07/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11650 MCCREE RD
DALLAS TX
75238-5224
US

IV. Provider business mailing address

11650 MCCREE RD APT 2034
DALLAS TX
75238-3245
US

V. Phone/Fax

Practice location:
  • Phone: 718-304-4906
  • Fax:
Mailing address:
  • Phone: 718-304-4906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number320878-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number958104
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number958104
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP61366158
License Number StateWA
# 5
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1099855
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: